THE W.E.S. E-JOURNAL

THE W.E.S. E-JOURNAL Vol. I, no 2 April, 2001 World Endometriosis Society President 2000 – 2002 John Rock M.D. Executive Committee: Jacques Donnez, MD Past president Robert Shaw, MD President-Elect Eric Thomas, MD Vice-President Jin Yong-Lee, MD Treasurer Rodolphe Maheux, MD Executive Secretary Council Members: Agneta Bergqvist, MD Michel Canis, MD Jacques Donnez, MD Johannes L.H. Evers, MD David Healy, MD Andre Lemay, MD Karl W. Schweppe, MD Paulo Spinola, MD Yuji Taketani, MD Paolo Vercellini, MD Central Business Office: Executive Secretary and redactor of the E-journal: Rodolphe Maheux, MD Staff: Lucy Felicissimo, PCO Danielle Laprise, Editor of the E-journal Micheline Maranda, Adm. Coordinator For further information, please contact: Micheline Maranda World Endometriosis Society 10, rue de l’Espinay, D1-719 Québec (Québec) Canada G1L 3L5 Telephone : (418) 525-4443 Facsimile : (418) 525-4481 E-mail : endo.world@fmed.ulaval.ca Message from the President The VII World Congress on Endometriosis in London was an outstanding success. The scientific program was well organized and of high caliber. I believe I speak for the Society in extending our sincerest congratulations to Bob Shaw and Eric Thomas for a superb Congress. Our Past President, Jacques Donnez chose as his presidential initiative the production of an educational CD-ROM on how to diagnose endometriosis. I shall continue this tradition by choosing as my initiative the formation of a committee to address scientific evidence for the various proposed types of endometriosis, to include retroperitoneal endometriosis which may be confused with adenomyosis, coelomic metaplastic endometriosis, or endometriosis that may result from retrotubal reflux. This is a timely and controversial topic that should be addressed by the Society. I urge members to contact the Secretary’s office in Quebec if they wish to participate on this important committee. IN THIS ISSUE Message from the President Society update from Executive Secretary Surgical treatment of infertility : The first and last expensive approach? Announcement of upcoming Symposium Details of the World Endometriosis Society ........ 1 ........ 2 ........ 3 ........ 4 ........ 5 Web Site:in developmentt The WES Newsletter is the official publication of the World Endometriosis Society. It is printed four times a year and distributed by e-mail to the members of the World Endometriosis Society. 1 Update of the Executive Secretary It is a great pleasure for me to present the second edition of the W.E.S. E-Journal. In this edition, you will find an article by Drs P.R. Koninckx and E. Mc Veigh on the surgical treatment of infertility. It is full of common sense and brings a new perspective for infertile women. We would appreciate your comments. If you wish, you can send us an e-mail with your comments at endo.wolrd@fmed.ulaval.ca. The VIII World Congress on Endometriosis will be held in San Diego, February 24-27th, 2002. Drs. Rock, Schenken and Young and their colleagues from the A.S.R.M. are coming up with a fantastic program. Please, reserve those dates today. San Diego is really a super destination, especially in February. Dr Eric Thomas, our vice-president and co-organizator of the last W.C.E. in London, has been appointed Vice-Chancellor of the University of Bristol. As such, he will stop practicing and doing research in endometriosis. He, therefore, resigned as vice-president of our Society. Not only our Society but all the field of endometriosis is loosing a leader. We wish him all the success possible in this new challenging part of his life. We ended our association with OBGYN.NET for the maintenance of our website. We believe that a smaller but independent website will allow us to better serve our members. Our new site is under development and should be available soon. We will keep you informed. Finally, it is time to renew your membership. I remember you that our annual fees are kept to the minimum (60.00 $ US). Our members will receive a rebate on the inscription’s fees for the VIII WCE in San Diego, free copies of the next W.E.S. E-Journal and also receive during the next few months our first CD on endometriosis. So don’t forget to renew your membership and if possible, ask one of your colleagues to join us. Only one signature of a regular member is needed for proposal of new members. For further information, contact the head office. Hoping to see you back in San Diego, Rodolphe Maheux, md Executive Secretary OUR MISSION K Promote the exchange of clinical experience, scientific thought and investigation among gynecologists, endocrinologists, researchers, biologists and other qualified persons interested in endometriosis. K Disseminate information about endometriosis. K K Foster research in endometriosis pathogenesis and treatment. Encourage and support collaboration among national and international societies interested in endometriosis. 2 Results of treatment Results of treatment vary widely, reflecting patient selection, age, referral bias, expertise and many other variables. Treatment outcomes have been compared in randomised clinical kids (RCT) and thoroughly performed meta-analyses, which SURGICAL TREATMENT OF INFERTILITY : THE FIRST AND LEAST EXPENSIVE APPROACH ? P.R. KONINCKX *,** and E. Mc VEIGH** *Dpt. Obstretrics and Gynaecology, UZ Gasthuisberg, Katholieke Universiteit, Leuven and **Nuffield, dpt. Obstetrics and Gynaecology, Radcliffe Hospital, Oxford UK. are extremely useful to achieve valid conclusions for specific questions. It should be realised however, that the number of specific questions which can be evaluated by RCT will always be relatively limited because of time and cost constraints. RCT moreover are not suited to answer complex questions with many variables as is often necessary in infertility treatment. This however may not be a major problem. If we consider infertility services as a whole, then with the mildness brought by overlooking 30 years of history, I cannot avoid the impression that in clinical medicine consensus The last 15 years have been witness to several important evolutions in infertility treatment. Microsurgery has been replaced to a large extend by endoscopic surgery. Simultaneously this surgical treatment is being performed by an increasingly large number of “endoscopic surgeons”, if compared to the previously limited group of “microsurgeons”. In vitro fertilisation (IVF) and other assisted reproductive technologies have over the same period reached maturity, and these services have become widely available. The changes in surgical treatment from microsurgery to endoscopy and the successes of IVF profoundly changed the profile of the “fertility specialist”. It even could change reproductive medicine as a subspeciality. Few are indeed those who still can claim to be expert in both assisted reproductive technologies and in advanced endoscopic surgery. Knowledge and skills have been moving from one person comprehensively overlooking infertility treatment to two areas which are increasingly less overlapping, and which in addition often are considered competitives. In addition results of treatment cannot easily be compared since results from surgery tend to be expressed as cumulative pregnancy rates whereas results from IVF are generally given as pregnancy rates per cycle. These fast changes over the last decade in infertility treatment merit reflection over results and costs of treatment and of organisation of infertility services. This article, reflecting personal opinions, wants to stimulate discussion in the benefit of both profession. reflection and atients and of our Another example is the salpingostomy for hydrosalpinx. Varying with technique, the damage to the inside of the tube and the degree of peritubal adhesions, CPR between 20% and 60% were reported. This statement is not contradicted by the observation that very severe tubal damage is associated with pregnancy rates so low that surgery becomes contra- indicated. Results of IVF are less clear, since life table analysis is hampered by the number of exposures which are always limited because of the effort and of the cost of treatment and also by counselling. The cumulative pregnancy rate thus always balances between what is theoretically possible and what is actually achieved. An overall real pregnancy rate around 50% per patient in an IVF clinic seems to be a realistic tends to prevail. This can best be illustrated by an example. Results of endometriosis surgery could be summarised as follows. The efficacy of the treatment of subtle lesions, and even of typical lesions (minimal to mild disease) has been debated, some studies showing an increased fertility following surgery, some studies suggesting that time to pregnancy was shorter, some showing little efficacy. Overall, however, there seems to be an agreement of a cumulative pregnancy rate between 30% and 60% after 1 to 2 years varying with the age of the woman and the duration of infertility. Also following surgery for cystic ovarian endometriosis and/or for deep lesions similar results are reached for the less severe lesions, and slightly lower results for the very extensive disease. 3 estimate. The recent debates discussing whether salpingectomy should be considered for hydrosalpinges because pregnancy rates in IVF increase following salpingectomy, is artificial and intellectually wrong. The aim of a fertility treatment is not to prove that one therapy is superior to another. The aim is to achieve the highest number of pregnant women at a reasonable cost and effort and with a minimal risk. Salingostomy and IVF are rather complementary treatments, although some individualisation taking into account aspects as age and tubal damage, is mandatory. The probability of a subsequent IVF pregnancy will not be jeopardised by performing a salpingostomy making the pregnancy rates for both treatments cumulative. A salpingectomy, on the contrary will only leave IVF as an option. R.C.T. comparing both treatment options, would thus give a strong answer to a wrong question. Common clinical logic defines both treatments clearly as complimentary in many women. Cost of treatment Costs, which cannot be avoided and which occur in all patients, will not be discussed. These comprise the fertility work-up including probably in most women a diagnostic laparoscopy. The endpoint of fertility treatment is babies. Each baby born carries the costs and risks of the treatments. In addition the time to pregnancy can be important especially in older women. The cost of a baby in Belgium can be summarised as follows. The surgical treatment of minimal and mild endometriosis carries the extra cost of 5 to 15 minutes of extra surgical time during the diagnostic laparoscopy (which amounts to a few 100 $). Even a salpingostomy during this diagnostic laparoscopy will increase surgery time by some 30 minutes only. The surgical treatment of severe endometriosis with a duration of surgery of a few hours and an hospitalisation time of 1 to 3 days will increase the bill to a few 1 000 $. Any of these calculations will estimate the cost of a baby born between a few hundred and a few thousand dollars. The cost of an IVF baby will be estimated at best around 10 000 $, an IVF cycle being some 2 500 $. These discrepancies in costs between at most a few thousand and at least 10 000 $ for a baby born following surgery and following IVF treatment respectively increase further if we take into account that following surgery generally several pregnancies can be achieved whereas IVF is a repetitive treatment. The risks of treatment are difficult to compare since e.g. costs of a surgical complication and of a twin pregnancy are difficult to estimate. The burden imposed upon society by multiple pregnancies, will however be difficult to counter-balance by the costs of surgical complications. Conclusions The impression that surgery has become the forgotten treatment should be brought in focus. Erroneously the results of surgery and of IVF are compared, forgetting that in most women they are complementary and successive treatments. Choosing one treatment instead of the other will automatically reduce the total number of pregnancies ultimately achieved. The cost of surgery is much lower than for IVF. The difference in cost even increases when a couple wants more than one child and when the burden of multiple pregnancies is taken into account. These considerations contrast sharply with the prevailing attitude of governments to regulate and limit IVF and assisted technologies services, in order to promote quality. Surgery, because of the endoscopic approach on the contrary becomes more disseminated, decreasing the expertise of the individual gynaecologist. Considering costs and cumulative pregnancy rates would thus suggest that quality concerns should be equally applied to fertility surgery as it is for IVF/ART services. In addition surgery should be favoured as a first treatment option in order to minimise overall cost. APRIL 20TH SYMPOSIUM "ENDOMETRIOSIS 2001" The Endometriosis Research Center (ERC) and Amgen/Praecis are pleased to announce that they will be presenting "Endometriosis "2001", an educational Symposium featuring the latest research and treatment on Endometriosis. The free Symposium, held in celebration of the ERC's 4th anniversary, will be presented Friday, April 20th, 2001 in Arlington, VA and later broadcast on the Internet. Furthermore, opinion leaders on Endometriosis will be presenting on various apsects of the disease. 4 WORLD ENDOMETRIOSIS SOCIETY HOW TO JOIN THE WES • Send an e-mail to the administrative coordinator, Mrs Micheline Maranda, at the following address : micheline. maranda@crsfa.ulaval.ca • Upon receipt, Mrs Maranda will send you the application form of the WES by e-mail. The annual fees for regular members are 90 $ Can. ± 60 $ US • Please note that if you are a member of theWES but not receiving the E-journal, please update your e-mail address by sending a message to micheline.maranda@ crsfa.ulaval.ca MEMBERSHIP BENEFITS • • • • Free reduction for all WES activities Free issues of the WES E-journal Information on all WES activities Participation in Society's General Assembly Meeting held during biennial World Congress Access to Society information on Web Site Free CD-ROM on the diagnosis of endometriosis (a value of 150 $ US) • • Arriving soon : Finally a visual idea of the free CD-ROM update, that will be offered to all W.E.S. members, edited by Professor Jacques Donnez on the diagnosis of endometriosis 5 Picture taken at the "Hôtel de Crillon" in Paris during the official reception of the last European Society of Gynecological Endoscopy (from left to right) : Drs. C. Sutton, V. Gomel, M-A. Bruhat and Madelenat. DON'T FORGET TO JOIN THE W.E.S. AND BENEFIT OF THIS SOCIETY'S FREE CD-ROM AND UPCOMING CONGRESS 6